Détails:On November 27th 1987 flight SA295 was scheduled to depart from Talpei's Chiang Kai Shek Airport at 13:00 UTC for Mauritius' Plaisance Airport and Johannesburg, South Africa on a scheduled international air transport service. Due to adverse weather and the late arrival of a connecting flight the departure time was delayed and the aeroplane took off at 14:23 UTC with 149000 kg of fuel, 43225 kg of baggage and cargo, 140 passengers and a crew comprising 5 flight crew members and 14 cabin crew members. The calculated flight time was 10 hours 14 minutes. The take-off was normal. At 14:56 UTC the crew communicated with Hong Kong Radar and thereafter routine position reports were given to the flight information centres (FICs) at Hong Kong, Bangkok, Kuala Lumpur, Colombo, Cocos Islands and Mauritius. At 15:55 a routine report was made to the Operator's base at Johannesburg. The information given was that the aeroplane had taken off from Taipei at 14:23, was flying at FL310 and that the arrival time at Mauritius was estimated as 00:35 UTC. At about 22:30 the pilot called Mauritius FIC, using HF radio, and advised that the aircraft had been at position 070° East at 22:29 at FL350 and that the time at position 065° East was estimated as 23:12. At 23:13 the position report of 065° East at FL350 was given to Mauritius FIC. The estimated time of arrival (ETA) over position 060° East was given as 23:58. About 23:45 the master fire warning alarm sounded on the flight deck. Somebody, probably the pilot, inquired where the warning had come from and received the reply that it had come from the main deck cargo. The pilot then asked that the check list be read. Some 30 seconds later somebody on the flight deck uttered an oath. The pilot called Mauritius Approach Control at 23:49 and said that they had a smoke problem and were doing an emergency descent to FL140.The approach controller gave clearance for the descent and the pilot asked that the fire services be alerted. The controller asked if full emergency services were required to which the pllot replied in the affirmative.At 23:51 the approach controller asked the pilot for his actual position. The pilot replied: "Now we have lost a lot of electrics, we haven't got anything on the aircraft now". At 23:52 the approach controller asked for an ETA at Plaisance and was given the time of 00:30. At 23:52:50 the pilot made an inadvertent transmission when he said to the senior flight engineer: "Hey Joe, shut down the oxygen left". From this time until 00:01:34 there was a period of silence lasting 8 minutes and 44 seconds. From 00:01:34 until 00:02:14 the pilot inadvertently transmitted instructions, apparently to the senior flight engineer, in an excited tone of voice. Most of the phrases are unintelligible. At 00:02:43 the pilot gave a distance report as 65 nautical miles. This was understood by the approach controller to be the distance to the airport. In fact it was the distance to the next waypoint, Xagal. The distance to the airport at that point was approximately 145 nautical miles. At 00:02:50 the approach controller recleared the flight to FL50 and at 00:03:00 gave information on the actual weather conditions at Plaisance Airport, which the pilot acknowledged. When the approach controller asked the pilot at 00:03: 43 which runway he intended to use he replied one three but was corrected when the controller asked him to confirm one four. At 00:03:56 the controller cleared the flight for a direct approach to the Flic-en-Flac (FF) non-directional beacon and requested the pilot to report on approaching FL50. At 00:04:02 the pilot said: "Kay". From 00:08:00 to 00:30:00 the approach controller called the aircraft repeatedly but there was no reply.The aircraft crashed into the Indian Ocean at a position determined to be about 134 nautical miles North-East of Plaisance Airport. The accident occurred at night, in darkness, at about 00:07 UTC. The local time was 04:07.

Within a few days drifing pieces of wreckage were found, but it took until January 28th, 1988 for the main wreckage field to be found on the Ocean floor, at a depth of 4400 meters.The cockpit voice recorder was recovered on 6 Jan. 1989.

Probable Cause:

PROBABLE CAUSE: Fire of an unknown origin had possibly: 1) incapacitated the crew; 2) caused disorientation of the crew due to thick smoke; 3) caused crew distraction; 4) weakened the aircraft structure, causing an in-flight break-up.; 5) burned through several control cables; 6) caused loss of control due to deformation of the aircraft fuselage.

The Combi type of configuration, with passengers and cargo on the same deck and provision for fire fighting on the cargo deck based on, inter alia, crew access to the seat of the fire and hand fire extinguishers to fight the fire, should be prohibited as creating an unacceptable risk to life and property, at least until such time as adequate provision is made to overcome the present shortcomings in fire detection, fire fightingequipment and fire fighting procedures.

Issued: --

To:

ZS-SAS (2)

For as long as Combi operations are permitted, effective fire detection and fire fighting systems, as laid down in the FAA AD No 89-18-12 R1 of August 10th 1989, should be strictly enforced. The recommendations are designed to eliminate any risk to life and property emanating from a main deck cargo fire, whatever the source, whereas the purpose of the FAA AD, though a step in the same direction, is, as stated therein, "To minimize the hazard associated with a main deck Class B cargo compartment fire...".

Issued: --

To:

ZS-SAS (3)

Since it has by no means been established that the aircraft was carrying dangerous goods, it is not for the Board to comment on the various ICAO and lATA documents on the subject. See for example Annex 18, ICAO Technical Instructions for the Safe Transport of Dangerous Goods by Air - Doc. 9284 - AN/905; ICAO Dangerous Goods Training Programmes - Doc. 9375 - AN/913 Books 1 - 6; and lATA Dangerous Goods Regulations; and see also RSA Regulations for the Carriage in Aircraft of Dangerous Goods, 1986. Nevertheless, in the Board\'s view continuing vigilance and research are required to eliminate all possible sources of packaging and car go ignition, whether from dangerous goods or otherwise.
Moreover, if Combi operations are to be permitted to continue, consideration should be given to revising the categories of dangerous goods to distinguish between those made up into pallets and those loaded in approved flame penetration-resistant containers.

Issued: --

To:

ZS-SAS (4)

Cockpit Voice Recorders
(a) should retain flight deck communications and sounds for the last hour, and not be limited to 30 minutes only;
(b) should be fitted with a "hot micn system, i.e. a system in which the microphones are connected to a recorder in a manner that ensures the recording of all cockpit sounds within the range of the microphones regardless of audio control panel selections;
(c) should be equipped with additional area microphones at the flight engineer\'s and supernumerary crew\'s station.

Issued: --

To:

ZS-SAS (5)

At least one pilot and the flight engineer should at all times use head-sets and boom microphones.

Issued: --

To:

ZS-SAS (6)

Both CVRs and DFDRs
(a) should be fire-protected in the aircraft, as should the wiring to the units;
(b) should where practicable have a back-up system of battery power in the event of fallure of the primary power source;
(c) should be fitted with a pinger system in which a first pinger operates for 30 days and a second 30-day pinger only commences operating after the first pinger ceases to function;

Issued: --

To:

ZS-SAS (7)

The Boeing 747 emergency check lists for "Upper and Main Deck Smoke Evacuation - Mixed Passengers and Cargo" and for "Main Deck Cargo Fire/Smoke - Mixed Passengers and Cargo" respectively require to be integrated. No provision appears to be made for the situation in which there is an uncontrolled fire in the main deck cargo hold and a smoke problem in the passenger cabin and/or cockpit.
The matter to be cleared up is whether the crew should follow the smoke evacuation check list if the fire is
still burning.

Issued: --

To:

ZS-SAS (8)

Means should be established by ICAO by which assistance in respect of underwater location searches for DFDRs and CVRs can be accelerated. The existence of standard procedures and agreements in respect of necessary actions and the funding thereof could be of great benefit and should be encouraged.

Issued: 16-MAY-1988

To: FAA

A-88-61

UNTIL FIRE DETECTION AND SUPPRESSION METHODS FOR CLASS B CARGO COMPARTMENT FIRES ARE EVALUATED AND REVISED, AS NECESSARY, REQUIRE THAT ALL CARGO CARRIED IN CLASS B CARGO COMPARTMENTS OF UNITED STATES REGISTERED TRANSPORT CATEGORY AIRPLANES BE CARRIED IN FIRE RESISTANT CONTAINERS. (Closed - Acceptable Alternate Action)

ESTABLISH FIRE RESISTANT REQUIREMENTS FOR THE CEILING AND SIDEWALL LINERS IN CLASS B CARGO COMPARTMENTS OF TRANSPORT CATEGORY AIRPLANES THAT EQUAL OR EXCEED THE REQUIREMENTS FOR CLASS C AND D COMPARTMENTS AS SET FORTH IN 14 CFR PART 25, APPENDIX F, PART III. (Closed - Acceptable Action)

Issued: 25-SEP-1989

To: B707, 727, 737, 747, 757, DC-8, DC-9, DC-10

AD 89-18-12

Directive for aircraft with a main deck Class B cargo compartment with regards to fire extinguishing systems, breathing equipment and the presence on board of an individual capable of fighting cargo fires. (Superseded)

Issued: 25-SEP-1989

To:

AD 89-18-12 R1

Revised directive for aircraft with a main deck Class B cargo compartment with regards to fire extinguishing systems, breathing equipment and the presence on board of an individual capable of fighting cargo fires. (Superseded)